Q) Which of the following statements is most accurate regarding axillary lymph node dissection (ALND) in breast cancer staging?
a) Level I and level II ALND requires the removal of at least 10 lymph nodes for accurate staging, and level III nodes should always be included in the dissection, regardless of the presence of gross disease in levels I and II.
b) The axillary dissection should include tissue from levels I and II, with a focus on the area inferior to the axillary vein, extending laterally to the latissimus dorsi muscle and medially to the pectoralis minor muscle, when there is no gross disease in level II nodes.
c) Level III nodes should be dissected in all cases of breast cancer for accurate staging, as they are always involved in metastatic spread.
d) Level I and level II ALND can be skipped in cases of clinically negative axilla, as there is no need for lymph node evaluation in the absence of suspicion of metastasis
Ans b) The axillary dissection should include tissue from levels I and II, with a focus on the area inferior to the axillary vein, extending laterally to the latissimus dorsi muscle and medially to the pectoralis minor muscle, when there is no gross disease in level II nodes.
In breast cancer surgery, axillary lymph node dissection (ALND) is used to evaluate the extent of cancer spread to the lymph nodes and to help stage the disease. The following key points should be noted:
Why Option b is correct:
Level I and II ALND are typically performed when there is a need to stage the axilla, and it is crucial to remove lymph nodes from these levels to accurately assess the presence of metastatic cancer. The dissection should focus on the tissue inferior to the axillary vein, from the latissimus dorsi muscle laterally to the medial border of the pectoralis minor muscle. This area corresponds to the levels I and II nodes.
If there is no gross disease detected in the level II nodes, further dissection into level III nodes is generally not needed. This ensures a more selective approach, avoiding unnecessary complications associated with dissection of more extensive lymph node regions.
Why the other options are incorrect:
Option a): While 10 lymph nodes are often considered the minimum number for accurate staging, level III nodes should not always be included in ALND unless there is gross disease detected in levels I and II. Dissecting level III nodes in the absence of disease is not routine practice due to the increased risk of complications.
Option c): Level III nodes are not routinely dissected in all cases. They are only considered when there is gross disease in level I and II nodes. This step is generally reserved for cases where there is clinically evident disease, as level III nodes are more challenging to access and carry a higher risk of complications.
Option d): In cases of clinically negative axilla, ALND may not be necessary, but for accurate staging and treatment decisions, lymph node evaluation (such as with sentinel lymph node biopsy or ALND) is still important. Skipping the dissection entirely without any evaluation is not appropriate, as there may be microscopic disease in the axillary nodes that could influence prognosis and treatment planning.
Q) Which of the following patients with operable breast cancer is the most appropriate candidate for preoperative systemic therapy?
A) A patient with ER-positive, HER2-negative breast cancer with a 1 cm tumor and clinically node-negative disease who desires breast conservation
B) A patient with HER2-positive breast cancer with a 3 cm primary tumor and clinically node-positive disease
C) A patient with triple-negative breast cancer with a 1 cm tumor and clinically node-negative disease who prefers mastectomy
D) A patient with ER-positive, HER2-positive breast cancer with a 1.5 cm tumor and no lymph node involvement
Correct Answer:B) A patient with HER2-positive breast cancer with a 3 cm primary tumor and clinically node-positive disease
Preoperative systemic therapy is generally recommended for:
HER2-positive or triple-negative breast cancer when the tumor is ≥cT2 (≥2 cm) or clinically node-positive (cN1).
Patients with a large tumor relative to breast size who desire breast-conserving surgery.
Patients with clinically node-positive disease (cN+) who may achieve node-negative (cN0) status with systemic therapy.
Option B meets these criteria with both HER2-positive disease and clinically node-positive status, making the patient an ideal candidate for preoperative systemic therapy.
Choice A: A patient with ER-positive, HER2-negative breast cancer with a 1 cm tumor and clinically node-negative disease who desires breast conservation
Explanation: This patient has an ER-positive, HER2-negative tumor that is small (1 cm) and clinically node-negative. These characteristics indicate a low risk of aggressive disease, and preoperative systemic therapy is typically not necessary for small, low-risk tumors. In this case, surgery would likely be the primary treatment option, followed by adjuvant therapy if needed.
Choice C: A patient with triple-negative breast cancer with a 1 cm tumor and clinically node-negative disease who prefers mastectomy
Explanation: Although this patient has triple-negative breast cancer (TNBC), the tumor size is only 1 cm and clinically node-negative. Preoperative systemic therapy is generally reserved for larger tumors (≥cT2) or node-positive disease in TNBC cases to improve outcomes or allow breast conservation. In this scenario, with a small, node-negative tumor, the preferred approach might be surgery first, as systemic therapy may not offer substantial additional benefits.
Choice D: A patient with ER-positive, HER2-positive breast cancer with a 1.5 cm tumor and no lymph node involvement
Explanation: This patient has HER2-positive breast cancer, but the tumor size is only 1.5 cm, which is below the ≥cT2 threshold for recommending preoperative systemic therapy. Additionally, the absence of lymph node involvement (cN0) indicates a lower burden of disease. While HER2-positive patients often benefit from systemic therapy, a neoadjuvant (preoperative) approach may not be necessary unless the tumor or nodal status meets certain thresholds (≥cT2 or ≥cN1).
Q) Known case of Ca breast presents with headache and signs of raised ICT. Solitary brain metastasis is confirmed on CT scan. How will you manage initially
Q) Paget disease classification in TNM what is false? ( Breast Onco)
1. Paget without invasive cancer is Tis
2. Paget with DCIS is Tis
3. Paget with underlying tumor classified as per tumor
4. Involvement of skin and nipple is stage 4
